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JIM DOYLE <br /> : GOVERNOR <br /> MICHAEL L.MORGAN <br /> SECRETARY <br /> b Division of Intergovernmental Relations <br /> 101 East Wilson Street,9th Floor <br /> � WISCONSIN DEPARTMENT OF Post Office Box 8944 <br /> N. ADMINISTRATION ((6,6088)) 53708 s944 <br /> Voice 267-3369 <br /> Fax(608)267-6917 <br /> DOA-7108(R07/2010) <br /> ss.59.72(3)&(5),and ss.59.43(2)(ag)1.&(e),Wis.Stats. <br /> Instructions: <br /> 1. Send all fees by the 16th of each <br /> Wisconsin Land Information Program month following the reporting month. <br /> PO Box 7869 2. Make check payable to: Wisconsin <br /> Madison, WI 53707-7869 Department of Administration. <br /> 3. Include this form with your payment. <br /> L_ _I 4. If you have questions please call <br /> (608)267-3369. <br /> Wisconsin Land Information Program <br /> Burnett County Recording Fee Submission <br /> Register of Deeds Name and Address: LIO Name and Address: Recording Period <br /> Jeanine Chell Jason Towne November I 203.2 <br /> 7410 County Road K#103 7410 County Road K#120 Month / Year <br /> Siren,WI 54872 Siren,WI 54872 ,� <br /> (NAME AND ADDRESS CORRECTION REQUESTED) <br /> Yes No 1 <br /> 1. Does the County Land Information Office established by the County Board per s.59.72(3),Wis.Stats., <br /> continue to perform the duties specified in s.59.72(3)(a-c),Wis.Stats.? X <br /> 2. Will/Has the county used$6 of each$25 fee collected under s.59.72(5),Wis.Stats.,to develop, d <br /> implement,and maintain the countywide plan for land records modernization? X <br /> 3. Will/Has County use/d$2 of each$25 fee collected under s.59.72(5),Wis.Stats.,for the provision of <br /> land information on the Internet,including the county's land information records relating to housing? <br /> X ' <br /> Certification <br /> I,the designee or contact person for the County Land Information Office, certify under the penalty of perjury that the information <br /> provided in questions 1-3 is t _- -nd correct to the best of my knowledge. <br /> 1 O 3 / I Z-- 715-349-2599 a <br /> /r0 Signature Date( m/dd/ cyy) Phone Number <br /> 4. Number of documents recorded and filed in the County Office of Register of Deeds under ss. 59.43(2)(ag)1. 486 ; <br /> &(e),Wis. Stats. a <br /> $ 972.00 <br /> 5. If questions 1-3 are all answered yes. multiply the amount on Line 4 by$2 and enter the total here... <br /> $ <br /> 6. If questions 1,2 or 3 are answered no, multiply the amount on Line 4 by$10 and enter the total here , <br /> 7. County Check Number: In the amount of: $ 972.00 , <br /> Certification <br /> I,the County Register of Deeds, certify under the penalty of perjury that the information provided in questions 4-7 is true and correct to <br /> the b y knowledge. <br /> �i '�u.�l4 �/C / -� C% 715-349-2183 <br /> R Signature Date(mm/dd/ccyy) Phone Number ' <br />